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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
54c* Surrogate Decision-Making
[C54:1] A patient is on a ventilator in the ICU for severe pneumonia. The patient does not have decisional capacity, no oral or written preferences, no living will, and no durable power of attorney are on record. The patient’s condition continues to deteriorate. The patient’s older offspring wants to withdraw life-support, but the patient’s younger offspring disagrees. What should be done?
[C54:2]
- A. Since the surrogates disagree, it is up to the practitioner to decide.
- B. Err on the side of life and keep providing life-support.
- C. Encourage discussion and help the surrogates form a consensus.
- D. Get a court order to appoint an independent proxy.
- E. Get hospital risk management involved and have them assess the situation.
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TAC: Think - Assess - Conclude
I. Think: What is the question?
[C54:3] What should a practitioner do when surrogates at an equal level of authority disagree?
II. Assess: Specify & Balance the four principles of bioethics
Patient: 1) Autonomy - Informed Consent
[C54:4] Since there are no oral or written preferences, no living will, and no durable power of attorney on record, medical decision-making authority now belongs to the surrogates. Both surrogates are legally and morally obliged to use substituted judgment, meaning that the patient’s reasonable goals, values, and priorities are used to make medical decisions, not the surrogate’s goals, values, and priorities. How substituted judgment decisions are to be conducted must be made clear to both surrogates, meaning that they are to be making decisions as if they were the autonomous patient. This means that the surrogates must clearly understand all aspects of informed consent: 1) the diagnosis, 2) treatment options, 3) goals or purposes of the treatment, 4) risks of harm and benefits of the various treatment options, including no treatment, 5) available alternatives including no treatment, and 6) have all their questions addressed. The practitioner must encourage discussion and consensus.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[C54:5] The practitioner has the professional obligation of beneficence (do good) and nonmaleficence (do no harm) to help the disagreeing surrogates to 1) discuss and come to a consensus as to what the patient would have wanted to have done under these circumstances using the patient’s reasonable goals, values, and priorities. If it is not possible to determine or come to an agreement on the patient’s reasonable goals, values, and priorities, then the surrogates will need to decide by 2) discussing and coming to a consensus as to what would promote the patient’s best interests.
Public Policy: 4) Justice
[C54:6] Legal surrogates are mandated by law and moral principles to make decisions using substituted judgment as if they were the patient using the patient’s reasonable goals, values, and priorities. If the patient’s reasonable goals, values, and priorities are impossible to determine, then the surrogates need to decide using the patient’s best interests.
[C54:7]
III. Conclude: Nationally or Professionally True Answer
[C54:8] The recommendation is to encourage discussion and consensus on what would maximize the patient’s best interests using the patient’s reasonable goals, values, and priorities. If the surrogates cannot agree using substituted judgment, then it may be necessary to decide based simply on what a reasonable person would consider being in their best interests.
Answer Options: [C54:9]
(Choice A) Since the surrogates disagree, it is up to the practitioner to decide.
A is the wrong answer. The legal authority for informed consent authority legally belongs to the surrogates, not the practitioner. The practitioner needs to help the surrogates understand all aspects of informed consent and make sure that the surrogates are trying to decide using substituted judgment, meaning using the patient’s reasonable goals, values, and priorities. If it is not possible to determine the patient’s reasonable goals, values, and priorities, then the surrogates must try to make a decision that will promote the patient’s best interests. During this process, the practitioner must encourage discussion and consensus.
(Choice B) Err on the side of life and keep providing life-support.
B is the wrong answer. There is no independent moral distinction between providing, withholding, or withdrawing life-sustaining treatment, as the moral distinction is dependent on what the patient’s wishes would have been, i.e., substituted judgment. Legal surrogates are the ones who have the legal authority for making that determination, and if it is not possible to determine the patient’s reasonable goals, values, and priorities, then the surrogates must try to make a decision that will promote the patient’s best interests.
(Choice C) Encourage discussion and help the surrogates form a consensus.
C is the correct answer. The practitioner needs to encourage discussion and help the surrogates form a consensus. If the surrogates cannot agree using substituted judgment using the patient’s reasonable goals, values, and priorities, then it may be necessary to decide based on what would maximize the patient’s best interests. This is a favorite Medical Boards exam question.
(Choice D) Get a court order to appoint an independent proxy.
D is the wrong answer. Once again, the legal authority belongs to the surrogates, and the practitioner needs to promote surrogate understanding of all aspects of the making of informed consent as if they were the patient, i.e., substituted judgment. If the patient’s reasonable goals, values, and priorities are not possible to come to an agreement, then the surrogate must try to determine what would promote the patient’s best interests.
(Choice E) Get hospital risk management involved and have them assess the situation.
E is the wrong answer. Once again, the legal authority belongs to the surrogates, and the practitioner needs to promote surrogate understanding of all aspects of the making of informed consent as if they were the patient, i.e., substituted judgment. If the patient’s reasonable goals, values, and priorities are not possible to come to an agreement, then the surrogate must try to determine what would promote the patient’s best interests.
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Assessment
Withdraw
Life-Support
Principles
Life-Support
X
X
Autonomy
Beneficence
X
X
X
X
X
X
Nonmaleficence
Justice
